Breastfeeding and Nipple Confusion

Caucasian mother breastfeeding baby son on sofa
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Nipple confusion, also called nipple preference, occurs when breastfed babies are given artificial nipples such as bottle nipples and pacifiers too soon after birth. A baby learns to suck differently on different types of nipples. The shape of a pacifier or bottle nipple is not the same as the shape of the nipple on a mother's breast. The flow of milk from a bottle nipple, whether it's pumped breast milk or formula, is different, as well. When the baby gets used to the difference in the sucking pattern or the difference in flow, the baby may become confused and begin to have difficulty sucking at the breast or refuse the breast altogether.

Nipple confusion does not happen with all babies. Some infants can use a pacifier and go back and forth from breast to bottle with no issue. However, some babies cannot.

It's more likely a baby will experience nipple confusion when a pacifier or bottle is introduced before breastfeeding is well established.

If possible, it's best to wait to introduce an artificial nipple until the baby is about 4 weeks old and breastfeeding well.

Nipple Confusion and Latch-On Problems

Babies with nipple confusion will often have latch-on difficulties. When they are breastfeeding, babies become accustomed to their mother's anatomy. For example, if a mother with flat or inverted nipples gives her baby a bottle too early, the baby will find that latching on to the bottle with it's protruding nipple is easier. Going back to the breast after that may prove frustrating. The flow of the bottle nipple is also faster, and the feeling is much ​more firm.

Nipple Confusion and Sucking Problems

Babies who are nipple confused may learn incorrect sucking patterns, which can cause some problems for moms such as sore nipples and a low breast milk supply. When babies take bottles, their mouths do not have to latch on to the artificial nipple the same way they latch onto the breast. They can gently glide onto the bottle whereas they must open their mouths wide to latch on to the breast. As a result, mom ends up with sore nipples because the baby's mouth is not latched onto her breast deeply enough. And, the supply of breast milk suffers since the milk ducts are not getting properly compressed.

Nipple Confusion and Breast Refusal

Too many moms worry that their baby isn't getting enough breast milk in the first few days after birth. Many offer bottles to satisfy them and, while the baby is content afterward, he has had more than his body should have. Keeping in mind that a baby's stomach is the size of a marble on Day 1, giving a 2-ounce bottle will stretch it out abnormally. At the next feeding, the baby goes back to the breast, but parents become frustrated that the baby is not getting the same amount as they did with the bottle. This is where the downward spiral begins, and the baby starts to refuse the breast.

Can Bottles Ever Have a Positive Influence on Sucking Behavior?

They sure can! Generally speaking, if a baby has been given a bottle or pacifier too early, he may end up with incorrect sucking patterns at the breast. At the same time, there are situations where special bottles may help babies who have sucking issues to learn to breastfeed correctly. Specific feeding bottles with long nipples reach the area where the hard and soft palates meet. These have been known to help babies with severe sucking problems to transition to breastfeeding since they mimic the process.

How to Avoid Nipple Confusion

The easiest way to avoid nipple confusion is to wait to introduce a bottle or pacifier to your baby. Exclusively breastfeeding is recommended for the first two to three weeks. It is important that the baby is latching on well and that your breast milk supply is well-established. At that point, you can introduce a bottle, perhaps one a day (preferably your expressed breast milk). Most babies can go back and forth from breast to bottle easily at this stage. If you have to return to work and need the baby to take a bottle, this is the ideal time to get started. You don't want to wait too long as you may miss your opportunity.

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Article Sources
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  1. Zimmerman E, Thompson K. Clarifying nipple confusion. J Perinatol. 2015;35(11):895-9. doi:10.1038/jp.2015.83

Additional Reading
  • American Academy of Pediatrics. New Mother’s Guide To Breastfeeding. Bantam Books. New York. 2011.
  • Lawrence, Ruth A., MD, Lawrence, Robert M., MD. Breastfeeding A Guide For The Medical Profession Seventh Edition.  Mosby. 2011.